Let’s take a deep dive into heart health!
Written by Dr Marissa Kelaher, Graphics by Dr Taisia Cech
Did you know, heart disease is the number one killer in New Zealand adults (and most other industrialised nations), even in women 😯
Almost 1 in 3 deaths in NZ adults are caused by heart disease, with someone dying from it every 90 minutes. About one in three deaths in New Zealand adults are attributed to heart disease, with someone dying from it every 90 minutes. And approximately 175,000 adults in New Zealand have known heart disease, while many others may be unaware of their condition.
Despite advancements in treatment, heart disease still takes a toll on health and life expectancy, impacting daily lives and diminishing quality of life for individuals and their families. And contrary to popular belief, while procedures such as cardiac stents and coronary artery bypass surgery save lives and can improve symptoms, they don't actually reduce the long-term risk of dying from heart disease.
Yet research shows up to 80% of heart disease is potentially preventable. While the changes in blood vessels that cause heart disease can start early - even in childhood.
So what are we doing wrong?
In this blog, we ‘re going to take a deep dive into heart disease, and most importantly, what you can do to help it! To understand this better, we need to first take a look at what actually causes heart disease.
How heart disease develops
Atherosclerosis - aka clogged arteries - is the build up of cholesterol within the arteries of the body, and is at the root of cardiovascular disease - which includes heart disease, strokes, and other blood vessel blockages.
When cholesterol accumulates in the arteries of the heart, it is referred to as coronary artery disease, which is commonly associated with heart disease. Atherosclerosis can also affect other major blood vessels, potentially causing strokes, peripheral vascular disease, loss of vision, or kidney failure.
This picture shows the stages of atherosclerosis via a cross-section of an artery - starting off with small amounts of cholesterol in our blood vessel walls, and eventually progressing to where it can block off blood flow completely
But contrary to popular belief, heart disease is not solely caused by high cholesterol levels.
It’s a complex process influenced by inflammation, the immune system, diet, physical activity levels, sleep quality, stress, environment and more.
Atherosclerosis develops gradually over time, with cholesterol building up in the arteries, eventually forming plaques that narrow the arteries and impede blood flow. These plaques can also rupture, leading to blood clots that completely block blood supply and result in heart attacks or strokes.
There are three main processes that cause atherosclerosis
So how does atherosclerosis actually occur? This is a bit more complex than just cholesterol buildup, as it also involves a couple of other processes, as we’ll cover next.
Cholesterol is transported in the blood through lipoproteins, with low-density lipoprotein (LDL) being the main type associated with plaque buildup.
As LDL particles are very small, they have the ability to breach our endothelium (the inner lining of blood vessels), and accumulate within the vessel walls. The concentration of LDL particles in the bloodstream plays a significant role in this process, as higher levels increase the likelihood of LDL entering the vessel walls and causing damage.
Lowering LDL levels through lifestyle changes and medication has consistently been shown to reduce the risk of heart disease.
This is reflected in multiple large studies showing that reducing LDL levels significantly reduces the risk of heart disease .
Every 1 mmol/L our LDL drops, our risk of heart attack or stroke reduces by 25% over the next 5 years.
However, it is important to note that endothelial dysfunction (when our endothelium doesn’t work the way it should), also plays a significant role in whether cholesterol causes atherosclerosis and damage, as it means that the LDL floating around in our blood is far more likely to turn into plaques and atherosclerosis, and also more likely to trigger off blood clots (leading to a heart attack or stroke).
This picture of an artery shows our endothelium (the inner layer):
Endothelial dysfunction can result from factors such as smoking, diabetes, high blood pressure, and other health conditions.
Finally, chronic inflammation is the other key factor that contributes to the development of atherosclerosis and heart disease.
When LDL cholesterol moves from our bloodstream into the vessel walls, it becomes oxidized, triggering the release of inflammatory markers and cytokines. These chemicals stimulate our immune system, leading to the accumulation of immune cells called foam cells in the vessel walls.
Over time, this process triggers off more inflammation, further impairs endothelial function, activates our immune system, and causes additional damage to the arteries.
So rather than just being an issue of high cholesterol, atherosclerosis is caused by a mix of endothelial dysfunction, a buildup of cholesterol particles in the blood vessel walls, and the body's inflammatory response to this cholesterol.
Which means targeting all these things is SO important to reduce the risk and progression of atherosclerosis.
This also means lifestyle and nutrition can play a massive role in preventing heart disease in the first place, as well as helping improve symptoms - as it addresses all of these at once, getting to the root cause of the issue!!
What are the risk factors for heart disease?
There are both modifiable and non modifiable risk factors for heart disease (ie ones we can change vs ones we can't).
It’s important to know about these, as they help give you (and your health providers) more clues regarding your risk of heart disease, and what you should be doing to reduce it.
Age is the most significant non modifiable risk factor, purely because atherosclerosis takes a long time to develop, so we are at higher risk the older we get.
What's important to note though, is that while we can't stop ourselves from getting older, we can reduce most other risk factors - and following on from this, the less risk factors we have, the less they can build up over time
The main MODIFIABLE risk factors (ones we can change) are:
high blood pressure (hypertension)
high cholesterol (hyperlipidemia)
tobacco use (smoking or vaping)
diabetes/insulin resistance.
Other risk factors include:
high body weight (obesity)
a family history of heart disease
inflammatory disorders (like lupus, psoriasis, HIV)
early menopause
pregnancy complications (particularly gestational hypertension, preeclampsia, preterm delivery)
kidney disease.
There are a variety of tests you can get to help determine your own risk of heart disease, we cover these at the end of this blog post.
It’s important to note that ECGs (electrical tracings of the heart) will NOT detect heart disease until damage to the heart (aka a heart attack) has occurred - so a normal ECG doesn't mean you're in the clear!
This means finding out your risk, and taking as many steps you can to reduce it, is the most important thing to do.
How does lifestyle affect heart disease?
Studies show that lifestyle plays an absolutely vital role in preventing heart disease- reducing our risk by up to 80%.
Most of us know the basics of how to prevent heart attacks - don’t smoke, eat a healthy diet, maintain a healthy weight, and get regular exercise.
This applies even in people with a higher risk of heart disease due to genetics (often alongside medications)
But exactly what does this mean, and are there other things that matter too?
In this next section, we'll take a deep dive into different lifestyle factors that can have an impact, and exactly what you can do about them. Overall, a healthy lifestyle makes a big difference when it comes to cardiovascular disease risk.
Large population studies show that simply staying active, minimising alcohol, not smoking and eating a healthy diet will reduce the risk of heart disease by 66%, risk of stroke by 60%, and risk of heart failure by 69%.
And findings from the Nurses’ Health Study suggest that consistently following an overall healthy lifestyle is even more effective - preventing 82% of heart attacks
And it's never too late - as lifestyle management improves outcomes and future risks even in people with existing heart disease who are also having this medically managed!
A 'heart healthy lifestyle' means:
eating an optimal diet
getting recommended amounts of regular exercise
limiting time spent sitting (being sedentary)
aiming to get 7-9 hours of quality sleep each night
keeping stress at a manageable level
not smoking
minimising or avoiding alcohol
avoiding air pollutants as much as possible and being aware of your environment
regularly spending time in nature if possible
staying socially connected
Eating for a healthy heart
Research shows that diet has a huge impact on heart health, with poor nutrition accounting for around 50-60% of heart disease!
This means that what we eat can have a huge impact on cardiovascular health.
In this section, we’ll explore the key components of a heart-healthy diet, highlighting the importance of specific food groups and explaining how they can benefit our hearts.
In general, for a heart healthy diet, aim to:
Limit saturated fat intake to less than 10% of total calories, focusing on reducing animal products, palm oil, and coconut oil. For more info on cholesterol and fat check out our blog post here
Emphasize whole plant foods such as fruits, vegetables, whole grains, nuts, seeds, and legumes.
Reduce refined carbohydrates, such as white flour, white rice, and white noodles.
Minimize added salt and sugar.
Increase dietary fiber consumption.
Avoid or limit ultra-processed foods and trans fats.
By following these simple guidelines, you can make a massive difference to your health health (and overall health!), as well as potentially reducing blood pressure, improving metabolic health, and more.
To learn about these concepts in depth (with tasty recipes to help you on your way), check out our Nutrition course or Reboot course, where we teach you all you need to know about eating for a healthier heart and life.
There are also other specific dietary patterns which have been shown to improve heart health, these include:
DASH (Dietary Approaches to Stop Hypertension) Diet: A plant focused diet that emphasizes fruits, vegetables, whole grains, lean proteins, and low-fat dairy while limiting saturated fats and sodium.
Mediterranean Diet: Focuses on whole grains, fruits, vegetables, fish, and healthy fats like olive oil.
Portfolio Diet: Incorporates foods known to improve cholesterol levels, such as nuts, plant sterols, soluble fiber, and soy products.
Plant-Based Diets (Vegetarian or Vegan): These exclude or limit meat and other animal products, reducing the risk of heart disease by approximately 30% and potentially reversing atherosclerosis.
Practical tips to eat for a healthy heart:
Increase plant food consumption, as research consistently links a higher intake of whole plant foods to reduced risk of heart attacks, stroke, and improved blood pressure. Aim for your diet to be at least 80% plants.
Choose healthy fats over low-fat options, favoring monounsaturated and polyunsaturated fats found in plant foods (such as nuts, seeds, avocados and olive oil) and fish.
Include omega 3 rich foods such as chia seeds, hemp seed, walnuts, linseed, and oily fish (if desired), aiming to eat 2 servings of oily fish per week, or at least 1-2tbsp/ day of plant sources
Limit saturated fat (found in butter, red meat, coconut oil, whole milk, palm oil, and (probably) too much cheese). Substituting 5% of your daily saturated fat intake with polyunsaturated fat is shown to potentially reduce heart disease risk by as much as 18%.
Prioritize fiber intake to improve cholesterol, blood pressure, and glucose levels. Include legumes, fruits, vegetables, and whole grains. Women should aim for at least 25 grams of fiber a day, and men at least 30 to 38 grams a day, although there are extra benefits the more fibre you eat
Minimize processed and packaged foods, which are often high in added sugars, salt, and unhealthy fats. These increase our risk of heart disease, stroke, diabetes and obesity- in one study, every 10% increase in UPF caused a 14% higher risk of cancer, and 10% higher risk of early death, while another study found that each additional serving of ultra-processed foods was associated with a 9% increase in death from cardiovascular disease, independent of other cardiovascular risk factors.
Substitute animal protein with plant protein to lower the risk of death from cardiovascular disease. Research shows that every 3% of plant protein we swap for animal protein, this can reduce our risk of death by 10%.
Limit added sugar and sugary drinks, aiming for no more than 9 teaspoons for men and 6 teaspoons for women per day.
Be mindful of sodium intake, primarily derived from processed foods. Opt for low-sodium alternatives and check labels for hidden sources of salt. High dietary sodium intake (>2000 mg per day) can increase blood pressure significantly, and also increases the risk of death from heart disease. Check nutrition labels, and aim for <2000mg/day, or less than 1500mg/day if you have high blood pressure.
Limit or avoid alcohol consumption for optimal heart health.
So in summary, to eat for better heart health, remember to go back to the basics!
Aim to eat a diet rich in veggies, fruits, whole grains, legumes, nuts and seeds, while minimizing animal products and packaged foods, and being aware of added salt and sugar. This will give you a good evidence based eating pattern, which can be individualised depending on your risk factors, genetics, and preferences.
And starting to read nutrition labels, while being mindful of what you eat by tracking nutrients like fibre, will benefit not just your heart health, but your overall health too!
What about exercise?
We all know exercise is good for us, but just how much of a difference can it make to our heart health, and what kind of exercise should we be doing?
A sedentary lifestyle can contribute significantly to high blood pressure, unwanted weight gain, increased cholesterol levels, and impaired glucose metabolism, while regular movement reduces the risk for coronary artery disease, heart attack, heart failure, hypertension, obesity, and diabetes, and also reduces the risk of death from heart disease and all other causes.
Exercise is a powerful tool for improving heart health, and you don't need to be a fitness enthusiast to reap its benefits.
Regular exercise helps heart health in numerous ways, and many of these benefits are independent of weight (ie they help regardless of how much you weigh)
Exercise reduces atherosclerosis, improves blood pressure and heart function, increases blood flow to the heart, lowers the risk of blood clots, enhances the health of blood vessels, reduces inflammation, and improves cholesterol, blood sugar, and insulin levels. Exercise also helps with stress reduction, benefiting overall heart health, and making us feel good!
In this next section of the blog, we'll explore the importance of exercise for heart health and give you practical tips to get moving.
Aerobic Exercise:
Aerobic or cardio exercise has been extensively studied and is still considered to be a cornerstone of maintaining a healthy heart.
Current guidelines suggest we should be aiming for 150-300 minutes of moderate-intensity exercise per week, with extra health benefits if you can do more. Moderate intensity exercise means you can still carry on a conversation, but feel puffed, and get a bit of a sweat on (this includes brisk walking, slow jogs, cycling etc)
And if this seems like a lot, even 15 minutes of moderate walking daily can reduce the risk of death from heart disease by 14% and add up to 3 years of life!
Exercise also offers even greater benefits to people with pre-existing heart disease, as studies have shown that for every 150 minutes of moderate exercise per week, the risk of further heart issues drops by 14% in people with existing heart conditions compared to 7% in those without.
Strength Training
Strength training is also super important for heart health, and may be an easier place to start if you have symptoms like shortness of breath or palpitations.
Building muscle mass not only helps our heart handle additional work but also improves our metabolism, glycemic control, and bone strength. Strength training is particularly effective in reducing visceral (tummy) fat, which is strongly linked with cardiovascular disease.
Aim to do strength training (any exercise which builds muscle - whether at the gym or using home weights or body weight) 2-3 times/week, working all major muscles in your body.
For optimal exercise for a healthy heart, research shows we should ideally include both aerobic exercise and resistance training into our weekly routine.
Aim for 150-300 minutes of moderate exercise per week, along with 2-3 days of strength training.
Don’t forget about sitting:
Sedentary behavior (including prolonged sitting), has been identified as an independent risk factor for premature heart disease. Research shows that people who sit the most have a 29% higher risk of heart disease compared to those who sit the least. Balancing prolonged sitting with high levels of moderate-intensity exercise can help mitigate some risks, however, it's important to note that excessive TV viewing (more than 3-4 hours/day) may have extra negative effects, possibly due to it’s association with unhealthy snacking habits.
Breaking up long periods of sitting is crucial to help reduce this risk.
Current recommendations include trying to move for 2 minutes and stand for 8 minutes for every 20 minutes of sitting. Some tips for incorporating movement into day to day life include taking breaks outside, walking during meals, using stairs, active commuting, standing during meetings, and finding active ways to relax after work.
Overall, exercise is a powerful tool we can use for better heart health, that provides numerous benefits regardless of weight.
Remember, every minute of physical activity counts, so start with small steps and gradually build up to a routine that works best for you. Your heart will thank you!
And to learn more about how exercise affects our body and mind, the details of how and what to do to get moving, and our top practical tips and resources, check out our Boost your activity and Reboot courses!
How does sleep affect our heart?
We may not automatically associate lack of sleep with heart health, yet it's so important that sleep is now included in the American Heart Association 'Life's essential 8'
These are considered to be the most important modifiable areas affecting heart health, and consist of not smoking, healthy weight, healthy diet,being physically active, getting 7-9 hours sleep per night, as well as having a blood pressure, good cholesterol and normal blood sugar.
Chronic insomnia, regardless of its cause, is linked with higher rates of heart disease and death from heart disease, as well as higher rates of hypertension and heart failure.
Some studies even show an association between insomnia and a higher future risk of high blood pressure and high cholesterol!
In addition, chronic lack of sleep makes us age faster, this includes making our heart and circulation age faster too.
Both lack of sleep (less than or equal to 5-6 hours) or too much sleep (greater than or equal to 10 hours), can have negative effects on heart health, while long work hours and lack of sleep are independent risk factors for heart disease in men - working more than 55 hours per week is linked to sleep disturbances, including shortened sleeping hours and difficulty falling asleep.
When we sleep well, this helps to 'switch off' our fight or flight response (reduces sympathetic nervous system activity), and switches on our rest and digest system. (parasympathetic tone).
This results in decreases in our heart rate, stroke volume (much much blood is pumped out each time our heart beats), blood pressure, and myocardial workload (how hard our heart has to work)
Sleep apnea is important to mention as well, as it is a major risk factor for heart disease - with sleep apnoea affecting around 10% of adults overall, but around 50%-75% of people with heart failure.
Sleep apnoea can also double the risk of atrial fibrillation (the most common type of heart arrhythmia).
Studies estimate that between 30-60% of people with cardiovascular disease (or are at high risk) will have sleep apnoea- so it should ideally be screened for and kept in mind when looking at heart disease risk.
Some of our top tips for getting a better night's sleep include:
Keep your bedroom for sleep and sex only, and try keep screens out of the bedroom
Aim to have your bedroom as dark and quiet as possible, and slightly cooler (around 18-20degrees)
If you struggle getting to sleep, turn clocks around so you can't see them!
Try a warm shower or bath before bed
Get exercise daily, ideally in the morning, and avoid vigorous exercise before bed
Dim the lights an hour or so before bed, and turn off screens (blue light and bright light can disrupt sleep cycles)
Try get natural light in the morning, ideally before midday
Try avoid food (especially sweet, salty or spicy food) or alcohol in the few hours before bed
Avoid coffee within 8-10 hours of bedtime
Create a 'wind down' routine for the hour or so before bed, to help you relax, this can include gentle stretching herbal tea, listening to quiet music, reading, journalling, or meditation- the key is to get your brain out of 'busy' mode and into 'rest' mode
For more sleep tips see our blog post here, or check out our Restore your Sleep mini course, or our full Reboot course, where we explore sleep in depth, what could be affecting your sleep, and practical ways to get a better nights zzz.
Stress - the hidden risk for heart health
Did you know that stress plays a significant role in heart disease risk and prevention?
Numerous studies have shown that chronic stress, along with depression, anxiety and PTSD, are major contributors to heart attacks and coronary artery disease.
Some reseach even suggests that stress can be as harmful to heart health as smoking!
One large study (the INTERHEART trial) showed that psychosocial factors such as stress and depression were directly responsible for 32% of heart attacks, worldwide, while the risk from a lifetime of smoking was only slightly more, at 35%
Chronic stress, (both early in life and during adulthood), can increase the risk of future coronary artery disease by 40%-60% , so it’s crucial to recognise when talking about heart health.
When we experience stress, our body releases hormones such as cortisol and catecholamines, which elevate blood pressure, heart rate, and cardiac output (how much our heart has to work).
When this stress is prolonged, it leads to heightened sympathetic tone (our fight or flight nervous system staying ‘switched on’), increased inflammation, vasoconstriction, and oxidative stress—all of which can impair heart function and increase the risk of heart disease.
Additionally, acute triggers such as stress, anger, and depressed mood can significantly increase the likelihood of heart attacks, while broken heart syndrome (Takotsubo cardiomyopathy) and arrhythmias can also be induced by intense physical or emotional stress.
The link between mental health and heart disease
Anxiety, depression, and post-traumatic stress disorder (PTSD) are all strongly associated with heart disease risk.
This partly due to their effects on our body (which are similar to the effects of chronic stress), partly due to an underlying common inflammatory pathway, and also due to the fact that if we are suffering from these, we are less likely to practice healthy behaviours (such as eating well, exercising, not smoking, and not drinking alcohol).
In contrast, studies have shown that treating mood disorders and improving mental health can positively impact heart health outcomes and prognosis.
Fortunately, there are lots of different strategies can help reduce stress and improve mood, and are also shown to help our heart health.
Heart-healthy diets and regular exercise (as we’ve covered) have been shown to improve mental well-being and decrease heart disease risk.
Mind-body approaches, such as relaxation techniques, meditation, and biofeedback can lower stress levels and improve heart rate variability, which in turn helps improve heart health and mental health. Slow belly breathing (at a rate of 6 breaths/minute), positive thinking, and volunteering, can all also improve blood pressure and heart health
Spending time in nature and engaging in outdoor activities is another great way to lower cortisol levels, reduce blood pressure, and improve overall heart health.
The key is finding things you enjoy, that help you feel well, and making them part of your daily life, as this is what counts most in the long term!
We take a deep dive into how our stress response works, the impact chronic stress can have on our body, how to recognise it, and ways to stop stress from taking over your life, in our Take Control of Your Stress course, and our full Reboot course.
The role of environment in heart health
Environmental factors, such as air pollution and noise, are increasingly being recognised as having an effect on heart health.
Fine particulate matter, even at low levels, has been identified as a major cause of heart disease, with clear links found between air pollution and higher rates of heart attacks in many major cities. For example, changes in air quality in Beijing are linked to a 50% increase in CVD mortality for men and 27% increase for women, while improvements in air quality in Finland, England, Wales, and Poland have all been linked to a drop in mortality rates from heart disease.
And air pollution is thought to be responsible for nearly 20% of cardiovascular deaths globally, causing an estimated 55,000 to 200,000 premature deaths in the U.S. per year.
Exposure to air pollution can lead to inflammation, endothelial dysfunction, hormonal changes, and increased sympathetic tone—all of which contribute to cardiovascular issues.
Perhaps most importantly, research has demonstrated that air pollution impacts heart health even at very low levels, lower than most national standards.
Smoking is also obviously highly harmful to heart health, but second hand smoke exposure is also bad for us.
Smokers die an average of 13-14 years sooner than nonsmokers, and have 2 times the risk of heart disease and 10 times the risk of peripheral vascular disease compared to nonsmokers, while non-smokers who are regularly exposed to secondhand smoke have a 27% higher risk of death from heart disease and a 23% higher risk of stroke.
This increased risk rapidly declines once people stop smoking, with nearly half the excess risk of CVD being eliminated within 2 years of quitting.
While we can’t always change our environment at a personal level, there are a number of steps we can take to minimize our environmental risk.
These include spending as much time as we can in green spaces, reducing noise levels, avoiding smoking and secondhand smoke, using air purifiers, and ventilating kitchens during cooking.
How being connected with others helps our heart
Relationships have a powerful influence on heart health - a lack of social support has been found to increase the risk of heart disease by 29% and stoke by 32%.
Loneliness has similar effects on the body to chronic stress, and also makes us more likely to follow unhealthy behaviors (such as eating poorly, not exercising, drinking alcohol, or smoking).
People with heart disease (or other chronic health conditions) have worse prognosis if they are socially isolated or lonely - with the effect on health being similar to smoking tobacco!
In fact one of the most famous studies on social connection (the Harvard study) found that social isolation is THE most important overall predictor for health and longevity.
Social isolation can impact blood pressure too - a study of men and women aged 50-68 years, found that loneliness at study onset could predict a cumulative increase in blood pressure at 2, 3, and 4 years of follow-up.
And perhaps not surpisingly, the people we are surrounded by also impact on our heart disease risk (and overall health). For example, if we have a friend who becomes obese, we have a 57% higher chance of becoming obese during the same time period, and a 171% higher risk of becoming obese in future. If we have friends who smoke, this also influences our likelihood of smoking.
Having friends who practice healthy behaviors, increases the likelihood that we will practice these behaviors too - our friendships can be powerful!
So don’t forget about community when you’re thinking about heart health- surrounding yourself with positive relationships, where you support one another, and feel heard and cared for, is a vital part of a healthy life ❤️
Learn more about social connection in our Reboot course, including tips to boost your connection and sense of purpose.
Know your heart risk score
So now we’ve covered how to improve your heart health, the last part of the puzzle is knowing your own heart risks!
Checking your heart disease risk is crucial for maintaining good health and preventing future complications, so in this last section of the blog post, we’ll cover different methods and tests that can provide extra insight into your individual risk factors for heart disease.
By being proactive and understanding your risk, this can help empower you to be able to make informed decisions about lifestyle changes, interventions, and medications as needed to improve your heart health.
New Zealand guidelines recommend heart health checkups at specific ages for different population groups. Māori, Pacific, and South-Asian men over 30 and women over 40 should consider checkups, while European men over 45 and women over 55 should consider heart health checks.
If you have a strong family history of heart disease, stroke, or diabetes, you should consider starting checkups at a younger age - so talk to your doctor about what is best for you.
A basic heart health checkup should include tests such as cholesterol panel, blood sugar, kidney and liver function, blood pressure, abdominal circumference, and smoking status.
Your GP will use this information to give you a ‘heart disease risk score’, however you can also use online risk calculators, such as the CVD Calculator (cvdcalculator.com).
These calculators are great, as they not only give you an assessment of your risk, but also show the potential benefits of different interventions like dietary changes and statin medications.
This means they can be valuable tools in understanding the impact of various factors on your heart health, and can help guide you in making informed decisions about lifestyle modifications and medical treatments.
We always recommend using these calculators in conjunction to discussions with your health providers around the risks vs benefits of any interventions, as they can give you individualised advice based on your personal and family risk factors.
And remember - cholesterol isn’t just about the separate numbers, it’s about the overall pattern too, as low HDL and high triglycerides can be just as harmful for your health as high LDL! For more details on cholesterol readings, blood sugars, and what to aim for, check out our cholesterol blog here and our insulin resistance blog here.
In addition to the basic heart health checkup, there are a few other optional tests that can provide more detailed information about your heart disease risk, although many of these carry an additional cost, so are not essential to get a heart disease risk score.
Apo B and lipoprotein (a)
Apo B is a protein that’s been getting a lot more attention lately, it transports "bad" cholesterol molecules around the body, and has been shown to be an independent risk factor for heart attacks. Some studies have suggested apo B may be a better marker for atherogenic risk in a variety of ways, as it is a measure of ALL types of bad cholesterol, not just LDL cholesterol (there are other types of ‘bad’ cholesterol that aren’t routinely measured on cholesterol tests, such as VLDL, and these can also cause atherosclerosis). This means it may give a more accurate picture of just how much ‘bad’ cholesterol is floating around (whereas LDL only checks for one type)
We know that reducing apoB levels (by statin or non-statin therapy) improves cardiovascular outcomes, so checking it can also give helpful additional information in whether statins are needed.
Recommendations for checking apo B still vary between different countries, but in general it's recommended to check apo B if you have any of the following, as standard heart risk calculators can under-estimate risk with these conditions:
a normal LDL but other heart risk factors
high triglycerides
diabetes
obesity
metabolic syndrome
very low LDL levels
Apo B is now funded in many NZ labs, but check with your doctor if this test could be right for you
Lipoprotein (a) (or Lp (a)) is another type of ‘bad’ cholesterol that is strongly associated with a higher risk of heart disease, aortic stenosis, and blood clots. It’s almost entirely genetically determined, meaning you only need to check it once in a lifetime. Unfortunately, this means it also does not tend to respond to diet and lifestyle changes or statin medications.
Lp (a) is important to be aware of, as it causes atherogenesis (plaque buildup in arteries), can increase the risk of blood clotting, and is also linked with a higher risk of aortic stenosis (a type of valvular heart disease in which the aortic valve of the heart thickens and impairs the exit of blood from the heart).
If you have elevated Lp (a), you have a 2 fold increased risk for premature coronary artery disease, a 2 to 4 fold increased risk of aortic stenosis, and a 3 fold increased risk of blood clots.
Lp (a) is not a funded test at present, but you could consider checking Lp(a) if you have any of these risk factors:
a personal or family history of premature coronary artery disease
familial hyperlipidemia (a genetic cause of high cholesterol)
recurrent heart attacks or other cardiovascular events despite good medical and lifestyle management
high LDL cholesterol that does not respond to statin treatment
if you have valvular aortic stenosis
if you have a first degree relative with known elevated Lp (a).
The guidelines on what we should do if we have elevated Lp (a) are still not that clear. We don't know if lowering Lp (a) can reduce the risk of heart disease, and as mentioned, we don't currently have any medications or lifestyle interventions shown to help, although there are current drug trials underway.
Yet since we know Lp(a) is a significant risk factor for heart disease, checking it can give a much more accurate cardiovascular risk.
If you do have elevated Lp (a), this means you should be much more aggressive with lowering all other risk factors (smoking, diabetes, LDL, blood pressure etc) as although these may not reduce Lp (a) directly, they'll reduce your overall heart risk.
It's also important to remember that it's a risk enhancing feature only ie there are plenty of people who have elevated Lp(a) who live their whole lives without a heart attack - it’s just one more piece of the puzzle!
Coronary Artery Calcium Score
The coronary artery calcium score (CAC) is a specialized CT scan that measures calcified plaque in the heart's arteries (calcification is a process that naturally occurs to plaque over time).
It can provide personalized insights into your heart disease risk, by comparing the amount of calcium in your arteries to an average person of similar age and gender.
A CAC score is a marker of atherosclerotic plaque burden and an independent predictor of future myocardial infarction and mortality - meaning a higher CAC score indicates a higher risk of a heart event,
It is not funded in NZ and costs around $800-1000, CAC scans are available at most radiology providers now on referral from your doctor. It involves a similar amount of radiation to a mammogram, does not require IV contrast or dye, and is very quick to do.
This test is particularly helpful for borderline or intermediate-risk people, as it can help determine the need for medications like statins.
It is NOT recommended if you have known coronary artery disease, or are experiencing symptoms that could suggest heart disease (such as chest pain or shortness of breath).
Your absolute CAC score is the best predictor of short term risk ( risk of a heart attack in the next 5-10 years), while the CAC percentile score is the best predictor of lifetime risk (so is particularly useful in younger people ie less than 50 years old).
They are most useful in:
asymptomatic low risk people with a strong family history of premature heart disease
people with elevated LDL who are otherwise low risk, who want to know their risk/benefit of starting a statin
people at intermediate risk of heart disease (10-20% 10 year risk on a heart risk calculator)
people who have been recommended to take statin therapy based on overall cardiovascular risk assessment but want more information - particularly older people whose risk is largely driven by age
diabetics aged 40-60 years old who are otherwise low risk (as traditional risk scores can underestimate risk in this group)
As CAC tests measure calcified plaque only, they aren't generally recommended in people younger than 40 years of age, as there is a higher chance of having soft (uncalcified) plaque in this age. Soft plaque tends to be far more common in people under 40, meaning that a low CAC score is less reliable, as it can miss significant soft plaque
However they can sometimes be considered in younger people with multiple risk factors for heart disease, or who have a strong family history of heart disease, but who would otherwise not be given medications.
A CAC score will give a reading between 0 and >400, with zero being very low risk, and >400 being very high risk. This can be useful to decide whether or not medications such as aspirin or statins are needed.
Risk scores are as follows:
CAC = 0. Very low risk, with risk of death <1% over 10 years.
CAC = 1-100. Low risk, with risk of death <10% over 10 years
CAC = 101-400. Intermediate risk, with risk of death 10-20% over 10 years
CAC = 101-400 & >75th centile. Moderately high risk with risk of death 15-20% over 10 years
CAC > 400. High risk, with risk of death >20% over 10 years
A coronary artery calcium score of 0 in people aged 40-75 years of age is a strong “negative risk factor.”, meaning they have a very low 10 year risk (with a mortality rate of about 1% over the next 10 years).
Guidelines suggest that people with a CAC of 0 who do not have diabetes, smoke, or have a strong family history of heart disease, to not generally need to take statins, so can avoid their use in the short term at least.
If you have a low score, you can consider getting a repeat scan after 5 years to re-assess risk.
If you are wondering about whether to get a CT calcium score, this discussion should always include your doctor, who can advise if it is a suitable test for you. They can also interpret the test, and advise you on the best course of action depending on results.
And to wrap it all up
We hope you’ve enjoyed this blog post on heart health, and are feeling more informed and empowered to take control of your own heart health!
While talking about heart health may feel overwhelming, remembering the basics can be powerful, as these have the potential to make a massive difference to your heart health and overall health.
These are:
aiming to eat a plant focused, mostly whole food diet, high in fibre, and low in added sugar, salt and saturated fat
moving your body daily, and trying to get a combination of cardio and resistance exercise (and remember to move regularly if you have a sedentary job!)
prioritising sleep, and creating healthy sleep habits
recognising the role stress can have, and taking whatever steps you can to reduce it
being aware of how environment and social connection impact on heart health, and building this into your day to day life
making sure you get your heart health checked, and be pro-active with tracking and managing this, in conjunction with your health providers
If you’d like to know more about any of the topics we’ve covered in this post, we have in depth Focus courses, as well as a full Reboot health transformation course. Plus we provide 1:1 in depth personalised health consultations NZ wide if you’d like some individualised help and advice.
Thank you for reading, and if you’ve found this helpful, please share with anyone you know who might enjoy it too!
And watch this space for more heart health topics in future - it’s such an important area to talk about, and one that can make the world of difference ❤️
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